Patient Data

Exhibits

The nurse is performing an assessment on the toddler. For each assessment finding, click to indicate whether the findings from the assessment should be a concern or not a concern to the nurse. Each row must have only one response option selected.

Rationale:

A. Slowly increase caloric content using enteral nutritional formula powder: Gradually increasing caloric density helps meet the infant’s energy requirements without overloading the gastrointestinal system, which is crucial for infants with heart failure and fatigue during feeds.

B. Feed the infant on demand: These infants are at high risk for fatigue, and feeding requires a significant amount of energy. This can lead to decreased intake and further weight loss. A structured feeding schedule is more appropriate to ensure adequate caloric intake.

C. Make sure the infant is well rested before feeds: Ensuring the infant is rested prior to feeding reduces fatigue, improves endurance, and increases the likelihood of adequate intake.

D. Wake the infant up to eat: Infants with heart failure and failure to thrive may not wake spontaneously for feeds; waking them ensures they receive adequate nutrition for growth and energy.

E. Stroke the cheek to encourage sucking: Tactile stimulation can promote sucking reflexes and help the infant feed more effectively, which is particularly important in fatigued infants.

F. Initiate a three-hour feeding schedule: Infants with heart failure fatigue easily. A structured feeding schedule, such as every 3 hours, is critical to ensure the infant receives consistent nutrition and hydration. This approach prevents the infant from becoming too hungry and ensures that feeding sessions are spaced out enough for the infant to rest and recover.

G. Feed for one-hour duration: Prolonged feeding times are not recommended for infants with fatigue; feeds should be effective but brief to prevent exhaustion.

H. Give gavage feedings via percutaneous endoscopic gastrostomy (PEG) tube: PEG tube feedings are not indicated at this time since the infant is able to feed orally with support and stimulation.

Rationale:

A. Obtain temperature assessment prior to aspirin administration: Monitoring temperature is important to evaluate the effectiveness of antipyretics. However, it does not address the risk of fluid imbalance or cardiovascular complications, which are more urgent in Kawasaki disease.

B. Maintain meticulous oral hygiene and lubrication of lips: Oral care helps prevent discomfort from mucous membrane changes such as cracked lips and strawberry tongue. Although important for comfort, it is not the priority during the acute inflammatory phase.

C. Provide passive range of motion exercises: Passive range of motion can prevent joint stiffness due to inflammation. While beneficial, musculoskeletal interventions are secondary to monitoring for complications related to cardiovascular status and hydration.

D. Monitor fluid intake and output and daily weight: Monitoring intake, output, and weight is crucial because Kawasaki disease can cause systemic inflammation, edema, and potential cardiac complications like myocarditis or heart failure. Accurate fluid balance assessment helps prevent worsening cardiac function and guides clinical management in the acute phase.